BSN 266 HESI V1
1. A client presents to the emergency department reporting chest painthat is
radiation to the left arm, shortness of breath, and diaphoresis. Which medica-tion
should the nurse anticipate being prescribed by the healthcare provider?
a. Fentanyl.
b. Hydromorphone.
c. Oxycodone.
d. Morphine.: D
Explanation: Morphine is commonly used to treat chest pain associated with my-ocardial
infarction (heart attack) as it provides pain relief, reduces anxiety, and has a vasodilatory
effect that can improve blood flow to the heart. The other medicationslisted
are not typically the first choice for managing chest pain related to a heart attack.
2. An adult who was recently diagnosed with glaucoma tells the nurse, "Itfeels
like I am driving through a tunnel." The client expresses great concernabout
going blind. Which nursing instruction is most important for the nurses toprovide
this client?
a. Maintain prescribed eye drop regimen.
b. Eat a diet high in carotene.
c. Wear prescription glasses.
d. Avoid frequent eye pressure measurement.: A
Explanation: Maintaining a prescribed eye drop regimen is crucial for managing glaucoma
and preventing further vision loss. While the other suggestions might be
helpful for overall eye health, adherence to the prescribed eye drop regimen is themost
important action to help prevent the progression of glaucoma.
3. Which information should the nurse include on the teaching plan of aclient
diagnosed with gastroesophageal reflux disease (GERD)?
a. Adjust food intake to three full meals per day and no snacks.
b. Sleep without pillows at night to maintain neck alignment.
c. Minimize symptoms by wearing loose, comfortable clothing.
d. Avoid participation in any aerobic exercise programs.: C
,Explanation: Wearing loose, comfortable clothing can help minimize GERD symp-toms
by reducing pressure on the abdomen and lower esophageal sphincter. Otherlifestyle
changes, such as smaller, more frequent meals, elevating the head of the bed, andavoiding
foods that trigger symptoms, are also important for managing GERD.
4. A client arrives to the emergency department reporting an intermittentfever
and night sweats for the past 3 weeks and has developed a productive coughcontaining small
amounts of blood. Which intervention should the nurse prioritize?
a. Move into airborne isolation.
b. Collect specimens for blood cultures.
c. Arrange transport for radiographic imaging.
d. Obtain a sputum sample.: A
Explanation: The client's symptoms (intermittent fever, night sweats, productivecough
with blood) are suggestive of tuberculosis (TB). The nurse should prioritize placingthe
client in airborne isolation to prevent the potential spread of TB to others whileawaiting
further assessment and testing.
5. A client receives a prescription for 1 liter of Ringer's intravenously tobe
infused over 6 hours. How many mL/hr should the nurse program the infusion pump to deliver?
(Enter numerical value only. If rounding is required, round tothe
nearest whole number.): 167mL
6. A client with eczema is applying 10% urea cream onto the affected skinareas. Which
finding reflects the expected therapeutic response?
a. Hydration of affected dry skin areas.
b. Reduced pain in eczematous areas.
c. Decreased weeping of ulcerations in affected areas.
d. Healing with a return to normal skin appearance.: A
Explanation: Urea cream is a moisturizing agent that helps hydrate and soften dry,rough skin
in clients with eczema. The expected therapeutic response would be hydration of the affected
dry skin areas. While the cream may also help alleviate some
symptoms, such as itching or pain, its primary purpose is to moisturize the skin.
7. The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing
abdominal pain. To help the client manage the pain, whichassessment data is most important
for the nurse to obtain?
a. Activity level of bowel sounds.
, b. Eating patterns of dietary intake.
c. Level and amount of physical activity
d. Color and consistency of feces.: B
Explanation: In clients with chronic pancreatitis, the nurse should assess eatingpatterns
of dietary intake to help manage persistent abdominal pain. The pain is often relatedto
the type and amount of food consumed, and adjusting the diet can help alleviate discomfort.
Clients are usually advised to eat smaller, more frequent meals, andavoid
high-fat foods.
8. A client with hyperparathyroidism reports a sudden monster of severeflank
pain. Which intervention should the nurse include in the client's plan ofcare?
a. Implement seizure precautions.
b. Initiate cardiac telemetry.
c. Administer a PRN dose of a laxative.
d. Begin straining all urine.: D
Explanation: Sudden onset of severe flank pain in a client with hyperparathyroidismmay
indicate the presence of kidney stones. The nurse should include straining all urinein
the client's plan of care to collect any passed stones for analysis and to monitor
the
progress of stone passage.
9. After falling down the basement steps, a client is brought to the emer-gency
room. X-ray confirms that the client's right leg is fractured. Following applica-tion
of a leg cast, which assessment finding warrants immediate intervention bythe
nurse?: C
Explanation: A pale right foot with sluggish capillary refill following the application ofa
leg cast may indicate compromised blood flow to the extremity, which requires immediate
intervention by the nurse. The other findings are expected after a fractureand cast application,
but do not warrant immediate intervention.
10. An older adult client with a long history of chronic obstructive pul-monary
disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The
client is anxious and is complaining of a dry mouth.
Which
1. A client presents to the emergency department reporting chest painthat is
radiation to the left arm, shortness of breath, and diaphoresis. Which medica-tion
should the nurse anticipate being prescribed by the healthcare provider?
a. Fentanyl.
b. Hydromorphone.
c. Oxycodone.
d. Morphine.: D
Explanation: Morphine is commonly used to treat chest pain associated with my-ocardial
infarction (heart attack) as it provides pain relief, reduces anxiety, and has a vasodilatory
effect that can improve blood flow to the heart. The other medicationslisted
are not typically the first choice for managing chest pain related to a heart attack.
2. An adult who was recently diagnosed with glaucoma tells the nurse, "Itfeels
like I am driving through a tunnel." The client expresses great concernabout
going blind. Which nursing instruction is most important for the nurses toprovide
this client?
a. Maintain prescribed eye drop regimen.
b. Eat a diet high in carotene.
c. Wear prescription glasses.
d. Avoid frequent eye pressure measurement.: A
Explanation: Maintaining a prescribed eye drop regimen is crucial for managing glaucoma
and preventing further vision loss. While the other suggestions might be
helpful for overall eye health, adherence to the prescribed eye drop regimen is themost
important action to help prevent the progression of glaucoma.
3. Which information should the nurse include on the teaching plan of aclient
diagnosed with gastroesophageal reflux disease (GERD)?
a. Adjust food intake to three full meals per day and no snacks.
b. Sleep without pillows at night to maintain neck alignment.
c. Minimize symptoms by wearing loose, comfortable clothing.
d. Avoid participation in any aerobic exercise programs.: C
,Explanation: Wearing loose, comfortable clothing can help minimize GERD symp-toms
by reducing pressure on the abdomen and lower esophageal sphincter. Otherlifestyle
changes, such as smaller, more frequent meals, elevating the head of the bed, andavoiding
foods that trigger symptoms, are also important for managing GERD.
4. A client arrives to the emergency department reporting an intermittentfever
and night sweats for the past 3 weeks and has developed a productive coughcontaining small
amounts of blood. Which intervention should the nurse prioritize?
a. Move into airborne isolation.
b. Collect specimens for blood cultures.
c. Arrange transport for radiographic imaging.
d. Obtain a sputum sample.: A
Explanation: The client's symptoms (intermittent fever, night sweats, productivecough
with blood) are suggestive of tuberculosis (TB). The nurse should prioritize placingthe
client in airborne isolation to prevent the potential spread of TB to others whileawaiting
further assessment and testing.
5. A client receives a prescription for 1 liter of Ringer's intravenously tobe
infused over 6 hours. How many mL/hr should the nurse program the infusion pump to deliver?
(Enter numerical value only. If rounding is required, round tothe
nearest whole number.): 167mL
6. A client with eczema is applying 10% urea cream onto the affected skinareas. Which
finding reflects the expected therapeutic response?
a. Hydration of affected dry skin areas.
b. Reduced pain in eczematous areas.
c. Decreased weeping of ulcerations in affected areas.
d. Healing with a return to normal skin appearance.: A
Explanation: Urea cream is a moisturizing agent that helps hydrate and soften dry,rough skin
in clients with eczema. The expected therapeutic response would be hydration of the affected
dry skin areas. While the cream may also help alleviate some
symptoms, such as itching or pain, its primary purpose is to moisturize the skin.
7. The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing
abdominal pain. To help the client manage the pain, whichassessment data is most important
for the nurse to obtain?
a. Activity level of bowel sounds.
, b. Eating patterns of dietary intake.
c. Level and amount of physical activity
d. Color and consistency of feces.: B
Explanation: In clients with chronic pancreatitis, the nurse should assess eatingpatterns
of dietary intake to help manage persistent abdominal pain. The pain is often relatedto
the type and amount of food consumed, and adjusting the diet can help alleviate discomfort.
Clients are usually advised to eat smaller, more frequent meals, andavoid
high-fat foods.
8. A client with hyperparathyroidism reports a sudden monster of severeflank
pain. Which intervention should the nurse include in the client's plan ofcare?
a. Implement seizure precautions.
b. Initiate cardiac telemetry.
c. Administer a PRN dose of a laxative.
d. Begin straining all urine.: D
Explanation: Sudden onset of severe flank pain in a client with hyperparathyroidismmay
indicate the presence of kidney stones. The nurse should include straining all urinein
the client's plan of care to collect any passed stones for analysis and to monitor
the
progress of stone passage.
9. After falling down the basement steps, a client is brought to the emer-gency
room. X-ray confirms that the client's right leg is fractured. Following applica-tion
of a leg cast, which assessment finding warrants immediate intervention bythe
nurse?: C
Explanation: A pale right foot with sluggish capillary refill following the application ofa
leg cast may indicate compromised blood flow to the extremity, which requires immediate
intervention by the nurse. The other findings are expected after a fractureand cast application,
but do not warrant immediate intervention.
10. An older adult client with a long history of chronic obstructive pul-monary
disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The
client is anxious and is complaining of a dry mouth.
Which
